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CLINICAL REFERENCEThe following Clinical Reference Document provides the evidence to support the Adolescent Obesity Time Tool. The following bookmarks are available to move around the Clinical Reference Document. You may also download a printable versionfor future reference.

In 2005, the American Medical Association (AMA), Health Resources and Services Administration (HRSA) and Centers for Disease Control and Prevention (CDC) convened an Expert Committee to revise the 1997 childhood obesity recommendations. Representatives from 15 healthcare organizations submitted nominations for the experts who would compose the three writing groups: assessment, prevention, and treatment. The initial recommendations were released on June 6, 2007 in a document titled "Appendix: Expert Committee Recommendations on the Assessment, Prevention and Treatment of Child and Adolescent Overweight and Obesity.” [1]

These terms provide continuity with adult definitions and avoid the vagueness of "at risk of overweight,” which has been confusing to patients and health care providers. [1]

Exceptions to the use of 85th and 95th percentile BMI values as cutoff points occur for older and younger children. [1]

For older adolescents, BMI of 95th percentile is higher than BMI of 30 kg/m2, the adult obesity cutoff point.

The committee therefore recommends that obesity in youths be defined as BMI of 95th percentile or BMI of ≥30 kg/m2, whichever is lower.

Use different terminology when communicating with patient/family.

More neutral terms such as weight, excess weight, body mass index, BMI, or risk for diabetes and heart disease can reduce the risk of stigmatization or harm to self-esteem. [1]

BMI is a screening tool to identify overweight, not a diagnostic tool.

Children with a BMI over these cut points do not necessarily have clinical complications or health risks related to overfatness. More in-depth assessment of individual children is required to ascertain health status. [9]

The likelihood of health risks increases in the 85th to 94th percentile (overweight) category; the risk is influenced by various factors including parental obesity, family medical history, and current lifestyle habits, as well as BMI trajectory and current cardiovascular disease risk factors. [1]

Recognition of the need for a third cutoff point to define severe obesity in childhood obesity seems to be evolving. [1]

An adolescent weighing 180 pounds and another weighing 250 pounds are in the same BMI category (>95th percentile) but face markedly different social and medical effects.

Children with a BMI above the 95th percentile (obese) are very likely to have obesity-related health risks, and should be encouraged to focus on weight control practices.

The expert committee proposes severe obesity to be defined as the 99th percentile BMI, which is BMI of >30 to 32 kg/m2 for youths 10 to 12 years of age and >34 kg/m2 for youths 14 to 16 years of age. [1]

The 97th percentile is the highest curve available on the growth charts – see Resources for tables for the 99th percentile cutoff points according to age and gender.

There is increasing prevalence of extreme obesity in children, putting them at high risk for multiple cardiovascular disease risk factors. [10]

In children aged 6 to 11, the prevalence of obesity more than doubled in the past 25 years, going from 6.5% in 1980 to 17.0% in 2006.

In adolescents, aged 12 to 19, the prevalence of obesity more than tripled in the same period, going from 5% in 1980 to 17.6% in 2006.

NHANES data going back to 1963 shows the trend -- the percentage of adolescents who are overweight or obese has increased steadily over the last 30 years. More than 3 times as many were overweight/obese in 2008 than in 1980. [14,15]

1976-1980 period – 5% of 12-19 yr olds were obese

1988-1994 period – 11% of 12-19 yr olds were obese

2007-2008 period – 18% were obese

Prevalence of overweight and obesity (BMI > 85th percentile) among children and adolescents ages 6-19 years, 1963-65 through 1999-2008

Age (years)

(1)

NHANES1963-651966-7

(2)

NHANES1971-74

NHANES1976-80

NHANES1988-94

NHANES1999-2000

NHANES2001-02

NHANES2003-04

NHANES2005-06

NHANES2007-08

6-11

4.2

4

6.5

11.3

15.1

16.3

18.8

15.1

19.6

12-19

4.6

6.1

5

10.5

14.8

16.7

17.4

17.8

18.1

(1) Excludes pregnant women starting with 1971-74. Pregnancy status not available for 1963-65 and 1966-70.(2) Data for 1963-65 are for children 6-11 years of age; data for 1966-70 are for adolescents 12-17 years of age, not 12-19 years.

The 2009 national Youth Risk Behavior Survey found that 10.9-13.1% of U.S. high school students were obese (BMI ≥ 95%). [16]

Demographic TrendsThe obesity epidemic has disproportionately affected some racial/ethnic groups. In 2003–2004, the prevalence rates were particularly high among black girls (24%) and Mexican American boys (22%). [17]

Rates have also increased among Native American and Asian American youths. [18,19]

Estimated that 3 of 5 obese young people already have at least one additional risk factor for heart disease, such as high cholesterol or high blood pressure; over 25% have two or more. [21]

Overweight and obese children and teens are approximately 10 times more likely than normal weight children to develop hypertension in young adulthood, three to eight times more likely to develop dyslipidemia, and more than twice as likely to develop diabetes. [22]

Type 2 diabetes mellitus used to be rare in children, but has become the most common type of diabetes diagnosed in several pediatric diabetes centers, and accounts for between 8% and 45% of newly diagnosed diabetes mellitus youths under age 19. [23, 23a]

Metabolic abnormalities increase with excess fat. [24]

Values for glucose, insulin, insulin resistance, triglycerides, CRP, interleukin-6, and systolic blood pressure, as well as the prevalence of impaired glucose tolerance, have been found to increase directly with increasing obesity. Correspondingly, adiponectin and HDL-C levels decreased with increasing obesity.

The Metabolic Syndrome (MetS) has been shown to be present in 28.7% of overweight adolescents (body mass index [BMI], >/=95th percentile) compared with 6.8% of at-risk adolescents (BMI, 85th to <95th percentile) and 0.1% of those with a BMI below the 85th percentile. [24a]

Data from the National Longitudinal Survey of Youth showed a significant relationship between obesity and changes in self-esteem during early adolescence, especially in girls. [30,31]

By 13 to 14 years of age, significantly lower levels of self-esteem were observed in obese boys, obese Hispanic girls, and obese white girls compared with their nonobese counterparts. Nearly 70% of white and Hispanic obese females demonstrated decreasing levels of self-esteem by early adolescence. [30]

Lower self-esteem in obese children was associated with significantly higher rates of sadness, loneliness, nervousness, negative self-image, social withdrawal, isolation and marginalization compared with obese children whose self-esteem remained unchanged. [31]

Obese children with decreasing self-esteem were also more likely to smoke and drink alcohol than obese children with unchanged self-esteem. [31]

IMPACT ON ADULT OBESITYObese youth are more likely than normal weight children to become overweight or obese adults, and therefore more at risk for associated adult health problems, including heart disease, type 2 diabetes mellitus, stroke, several types of cancer, and osteoarthritis. [32]

Obesity in childhood is an important early risk factor for much of adult morbidity and mortality. [33,34]

The probability of childhood obesity persisting into adulthood is estimated to increase from approximately 20% at 4 years of age to approximately 80% by adolescence. [35]

Approximately 80% of children who were overweight at aged 10–15 years were obese at age 25. [36]

Too few calories expended for the amount of calories consumed, partially mediated by genes. [26]

Three components are driving the obesity epidemic: [40]

The ubiquitous availability of high energy food, and media promotion of these foods,

The decline in everyday activity, and

A controlling factor in that humans evolved in an environment prone to food shortages, resulting in our natural drivers being geared to consuming more than we need. Our natural checks serve to answer to hunger and much less to excess.

Overeating and sedentary habits are promoted by our lifestyle.

Changes that typically occur during adolescence exaggerate the discrepancy in energy balance:

For many reasons, including fewer mandated school physical education programs, lack of safe areas for exercise, and the dominance of TV as a form of entertainment, physical activity levels are lower now than they were 20 years ago.

Caloric intake has increased remarkably because of the availability of fast foods that are high in calories and because of the lack of adult supervision in the lives of many children.

More than 4 out of 5 adolescent females do not consume enough calcium. [52]

Consumption of milk, the largest source of calcium, has decreased 36% among adolescent females in the last 25 years. [53]

Other factors associated with excess caloric intake:

Lower socioeconomic status -- fewer fruits and vegetables and a higher intake of total and saturated fat. [59-61]

Belonging to an ethnic group – all groups consumed more soda and fewer servings of fruit, vegetables, and milk than recommended for a healthy diet (2001 California Health Interview Survey -- adolescents aged 12 to 17 years). [63]

Advertising:

25%-70% of the 40,000 ads/year are for food, much aimed directly at children, a third containing misleading nutrition information, and $13 billion/year on restaurant and food ads. [65]

ENERGY EXPENDITURERelationships between sedentary behavior and adolescent overweight cannot be explained by using single markers of inactivity, such as TV viewing or video/computer game use. [66]

Many factors contribute, and it is the combination that results in the decline of energy expenditure.

The 2009 national Youth Risk Behavior Survey indicates that among U.S. high school students: [67]

23% do not get the recommended amount of physical activity,

Nearly half of school age adolescents do not attend physical education classes,

1 in 3 watch at least 3 hours of TV on an average school day, and

1 in 4 play video or computer games, or use computer for other than schoolwork, for 3 or more hours on an average school day.

More screen time, more overweightNearly 1 in 3 adolescents who have at least 5 hours of screen time daily are overweight vs. 1 in 8 who have no more than 2 hours of screen time daily. [68]

2 out of 3 children watch at least 2 hours of TV daily, more than 1 in 4 watches at least 4 hours per day. [69]

Those who watched 4 or more hours of television per day had significantly greater BMI, compared with those watching fewer than 2 hours per day. [69]

Having a television in the bedroom is a strong predictor of being overweight, even in preschool-aged children. [70]

Less physically active behaviorsNational survey data indicate that children are currently less active than they have been in previous surveys. [67,72-74]

With increasing urbanization, there has been a decrease in frequency and duration of physical activities of daily living for children, such as walking to school and doing household chores. [72]

Changes in availability and requirements of school physical education programs have also generally decreased children’s routine physical activity, with the possible exception of children specifically enrolled in athletic programs. [73]

All these factors play a potential part in the epidemic of overweight. [71]

National survey data indicate that 1 in 5 US children 8 to 16 years of age reported 2 or fewer bouts of vigorous physical activity per week. [72]

Less school physical activity

Daily participation in school physical education among adolescents dropped 14 percentage points over the last 13 years — from 42% in 1991 to 28% in 2003. [73]

Less than one-third (28%) of high school students get recommended levels of physical activity. [74]

Less than half of US schools offer P.E., and 1 in 4 adolescents don’t do any activity outside of school. [75]

UNHEALTHY WEIGHT LOSS PRACTICESA large number of high school students use unhealthy methods to lose or maintain weight. A nationwide survey found that during the 30 days preceding the survey, 12.3% of students went without eating for 24 hours or more; 4.5% had vomited or taken laxatives in order to lose weight; and 6.3% had taken diet pills, powders, or liquids without a doctor's advice. [76]

Within the community: Sidewalks, bike paths, and parks encourage walking or biking to school as well as participating in physical activity. Access to affordable, healthy food choices in neighborhood food markets can increase purchasing of healthy foods.

Clinicians, in general, have a poor self-efficacy when it comes to managing childhood obesity. Fewer than 2 out of 5 believe they can effectively manage their adolescent patients’ excess weight, and fewer than 1 in 8 feel they can be "highly effective.” [83]

Better counseling tools, an on-site dietitian and patient educational materials were cited as the greatest ways to improve obesity management.

Data from the 1999-2002 NHANES showed that only 4 in 10 overweight adolescents ages 12-15 years and half of overweight 16-19 year olds had been told by a doctor or other health-care professional that they were overweight. [84]

Diagnosis of overweight or obesity ranges from 17% to 29% among children and adolescents who have BMI>85th percentile [85-87].

Most pediatricians and PNPs routinely evaluated blood pressure, but a minority routinely looked for orthopedic problems, insulin resistance, and sleep disorders. Less than 1 in 10 followed all recommendations for history and physical examination. [89]

Percentage who do the assessment "most of the time" or "often" with overweight/obese children

COUNSELING PRACTICESThere is a distinct lack of research into counseling practices specifically targeting overweight or obese adolescents. For one thing, adolescents have the lowest rates of outpatient visits among all age groups, with particularly low rates among boys and ethnic minorities. [94]

Rates of risk behavior screening and counseling remain lower than recommended due in part to time constraints, inadequate reimbursement, and limited ancillary support. [94,94a]

Rates of diet, exercise and weight management counseling are much lower than they should be. [95]

One review of 633 family practice visits showed that weight loss counseling occurred with only 8% of overweight children. [96]

A random sample of a nationally representative sample found that approximately half of pediatricians reported always counseling about maintaining a healthy weight. [97]

Data from the National Ambulatory Medical Care Survey for the 3-year period, 1995-1997 showed that any preventive health counseling occurred in only 15.8% of family physician visits and 21.6% of pediatrician visits. The length of consultation increased from 13.8 to 17.6 minutes if counseling was included. [97a]

Counseling – Diet and ExerciseData from the National Ambulatory Medical Care Survey for 1997-2000 show that counseling services were documented for 39% of all adolescent general medical/physical examination visits. [94]

Diet and exercise were the most frequent counseling topics, but were included in only 26% and 22% of visits. [94]

Just over a third (38%) of youth 10 to 18 years old reported discussing sugar-sweetened beverages, fast food consumption or television viewing (41%) with their clinicians during an annual physical exam. [98]

Significant disparities exist in the rates of counseling in minority groups. [99]

INCIDENCE OF COUNSELING AND SCREENING (%) [94]

TYPE

WHITE

BLACK

HISPANIC

Tobacco cessation

5

7

4

Growth/development

62

47

46

Injury prevention

29

20

22

Diet

52

44

44

Exercise

13

11

10

Only 6.5% of adolescent ambulatory visits were for well care, less than 1% for obesity.

Counseling for diet (72% vs. 28%) and exercise (52% vs. 23%) was more frequent at acute visits than well visits. [100]

Programs to increase the diagnosis of obesity could improve diet and exercise counseling rates.

Diet counseling was reported for 88% and exercise counseling was reported for 69% of visits with an obesity diagnosis compared with 36% and 19% during well visits without a diagnosis of obesity.

The problem is that obesity was diagnosed in less than 1% of visits. [95]

There are opportunities for the already practicing physician to be taught strategies to prevent and manage childhood obesity. [102-104]

A survey of pediatric residents on their knowledge and attitudes about obesity prevention and management confirmed that their knowledge and counseling skills were below expectation. [105]

Implementation of an "Obesity Prevention in Pediatrics" curriculum improved their knowledge, skills and comfort level in the recognition, evaluation and counseling of both obese and overweight pediatric patients and their families. [105]

Two CME trainings on pediatric overweight assessment and management for clinicians and staff in a managed care system resulted in a significant increase in the utilization of some tools and practices, including charting BMI-for-age percentile and using a nutrition and activity self-history form. [106]

Training and tools for residents and community pediatricians improved their confidence, ease, and frequency of obesity-related counseling. Widespread implementation of educational interventions for community practitioners could change the way physicians counsel patients to prevent the often frustrating problem of childhood obesity. [106a]

Assess all children for obesity risk to improve early identification of elevated BMI, medical risks, and unhealthy eating and physical activity habits.

Calculate and plot BMI on a growth chart at least annually.

Accurately measure height and weight; measure height without shoes

BMI is very sensitive to measurement errors, particularly height;

A standard measurement protocol as well as training can improve accuracy.

Calculate BMI, plot on growth chart

BMI = [Wt in Pounds / (Ht in inches) x (Ht in inches)] x 703 OR

BMI = Wt in kg / [(Ht in Meters) x (Ht in Meters)]

Make a weight category diagnosis using BMI percentile:

< 5%ile Underweight

5-84%ile Healthy Weight

85-94%ile Overweight

≥ 95%ile Obesity

2. Measure Blood Pressure

PHYSICIAN CONSULT

1. Take A Focused Family History (first and second degree relatives)

Parental Obesity - One obese parent more than doubles the risk of becoming obese [114a]; an obese mother is a stronger risk factor (more than triples the risk) [114b,114c] and if both parents are obese the risk is 5 to 8 times higher than if neither parent is obese. [114d, 114e]

Medical conditions that are more likely with both excess weight and family history:

Type 2 diabetes

Cardiovascular Disease (CVD)

CVD risk factors – hypertension, hyperlipidemia

Offices should review and regularly update family history regarding first- and second-degree relatives. Checklists of symptoms and family history for patients or parents to complete can expedite this process.

2. Screen For Current Medical Conditions And Future Risks

Obesity-related medical conditions affect almost every organ system in the body.

A review of systems and a physical examination should screen for these conditions (See Resource – Table 5)

Consumption of foods that are high in energy density, such as high-fat foods

Number of fruit and vegetable servings consumed each day

Number of meals and snacks consumed each day and quality of snacks

Frequency of family meals

For physical activity assessment, the following behaviors should be addressed:

Time spent in moderate physical activity each day (including organized physical activity and unstructured activity, including play), to estimate whether the goal of 60 minutes of moderately vigorous activity each day is achieved

Routine activity patterns, such as walking to school or performing yard work or household chores

Sedentary behavior, including hours of television, videotape/DVD, and video game viewing and computer (screen time)

Tools to Assist Behavioral Assessment

Several tools have been developed to aide this part of the assessment [See Resources section for links].

Set realistic goals to reach target behaviors in steps. For example, begin with 15 minutes of physical activity per day and work up to 60 minutes, or target 2 or 3 behaviors in the beginning and add more behaviors with time.

Follow-up visit frequency tailored to the individual.

Expect imperfect adherence and tell patient/parent that they are making progress even if they do not achieve their goals every day.

Focus on successes and not failures.

Follow-up:

Typically monthly, but tailored to individual needs.

No improvement in 3 to 6 months, consider moving to stage 2, if patient/family are ready.

STAGE 2 – A More Structured ProtocolDiffers from Stage 1 in support and structure provided; target behaviors are same, but eating and activity plans are more specific.

Goal remains weight maintenance with decreasing BMI as age and height increase.

If weight loss occurs, should not exceed 2 lb/week.

Office Systems:

Becomes more important and involved in interventions; more staff roles

Provider’s office staff can provide much of this treatment, with some additional training.

Some practices find group sessions to be effective and efficient.

Eating plan requires a dietitian or a clinician with training in creating eating plans.

Staff with training in motivational interviewing and monitoring and reinforcement techniques can establish initial goals with families and see them for follow-up.

Referral to a physical therapist or exercise therapist can help with physical activity habits.

Monthly office visits are most appropriate, but should be tailored to individual needs.

Recommendations:

Employ a plan for a balanced macronutrient diet, emphasizing foods low in energy density (e.g., with high fiber or water content).

Use structured meals and snacks (breakfast, lunch, dinner, and 1 or 2 snacks per day) with no food or calorie-containing beverages at other times.

Planned, supervised physical activity or active play for at least 60 minutes per day.

Limit screen time to only one hour per day.

Monitor behaviors by using logs (for example, record minutes watching television and keep a 3-day record of food and beverages consumed)

Plan reinforcement for achieving targeted behaviors.

Follow-up: Same as Stage 1

Typically monthly, but tailored to individual needs.

No improvement in 3 to 6 months, consider referral to a Stage 3 program, if patient/family are ready and a suitable program is available.

STAGE 3 – A Comprehensive Multidisciplinary InterventionIntensity of behavior changes, frequency of visits, and specialists involved are all increased.

Usually exceeds the capacity of a primary care office. However, an office or several offices could organize specialists to offer this kind of a program.

Group visits more common.

Systematic evaluation of body measurements, dietary intake, and physical activity conducted at baseline and at specific intervals throughout the program.

Goal is weight maintenance or gradual weight loss until BMI is <85th percentile, with weight loss not exceeding 2 lb/week.

Eating and activity goals are the same as in stage 2. Activities include:

Follow-up:Weekly visits for a minimum of 8 to 12 weeks, with subsequent monthly visits.

When to consider Stage 4:

BMI of >95th percentile who have significant co-morbidities AND who have not been successful in stages 1 to 3 OR

BMI of >99th percentile who have shown no improvement in stage 3

STAGE 4 – An Intensive Pediatric Tertiary Weight Management CenterImplemented by a multidisciplinary team with expertise in childhood obesity, operating under a designed protocol.

A full range of protocols is used, including continued diet and activity counseling, meal replacement, very low-calorie diet, medication, and surgery.

KEYS TO SUCCESSClinical JudgmentClinicians must exercise judgment, not only in assessing the child’s health and designing an intervention, but perhaps even more importantly in communicating with the child and family.

No formula exists to integrate BMI pattern, family background, and health behaviors and attitudes into an optimal intervention.

Clinician may conclude that an overweight child is not "overfat” and reinforce prevention messages appropriate for children with healthy BMI values. [1]

Attention to body image issues

Should be discussed with all adolescents – as many as half of adolescents trying to lose weight were not overweight. [119]

Emphasize learning healthy lifestyle behaviors and habits, rather than a specific time frame.

Avoid setting specific time frames for weight loss.

Child­hood weight-management programs based on lifestyle interventions were more successful in the short term and the long term. [120]

Interactions between behaviors make it difficult to analyze the impact of any individual behavior. All of the behaviors play a role.

If greater sugar sweetened beverage intake, larger portion sizes at all meals and snacks, more-frequent snacks, more ready-to eat foods, more restaurant eating, more television viewing, fewer physical education classes, less walking to and from school, less outside play at home, more escalators, elevators, and automatic doors, and so forth, all coexist, then the impact of any one of those behaviors on obesity prevalence may be unmeasurable.

Mixed evidence (ME) -- Some studies demonstrated evidence for weight or energy balance benefit but others did not show significant associations, or studies were few in number or small in sample size.

When evidence is not available -- The panel considered the literature, clinical experience, the likelihood of other health benefits, the possible harm, and the feasibility of implementing a particular strategy before including it in recommendations.

For PREVENTING weight gain -- Evidence supports the following: [1]

BEHAVIOR RECOMMENDATIONS – PREVENTION

CONVINCING EVIDENCE

Limit consumption of sugar-sweetened beverages

Limit TV and other screen time to 2 hours or less per day

Remove TV and other screens from primary sleeping area

Eat breakfast daily

Limit eating out at restaurants, especially fast food restaurants

Family meals in which parents and children eat together

Limit portion sizes

MIXED EVIDENCE

Consume recommended quantities of fruits and vegetables

LITTLE EVIDENCE BUT CONSENSUS OF EXPERT OPINION

≥1 hour of moderate to vigorous physical activity each day

Limit consumption of energy-dense foods

Eat a diet rich in calcium, high in fiber and with balanced macronutrients

There is legitimate concern over the stigmatization of overweight and obese children. [123,124]

Health care visits are a good place to identify excess weight, because the setting frames the condition as a health problem and because the visit is private.

Clinicians must take responsibility for identification but must approach the subject sensitively, to minimize embarrassment or harm to self-esteem.

Expert committee recommends the clinical terms overweight and obesity for documentation and risk assessment but the use of different terms when communication with adolescents. [1]

Obese adolescents prefer the term "overweight.” [125]

Clinicians should discuss the problem with individual families by using more-neutral terms, such as "weight,” "excess weight,” and "BMI.” [1]

The real challenge in obesity counseling lies in the process of influencing families to change behaviors when their habits, culture, and environment often promote less physical activity and more energy intake.

Handing families a list of recommended eating and activity habits as if it were an antibiotic prescription is rarely effective. [1]

INVOLVING THE FAMILYTreatment of obesity in children, like the treatment of obesity in adults, is expensive, lengthy and more effective if the whole family is involved. [126,127]

The goal should be prevention in the entire population, with particular attention to more susceptible ethnic groups. [128]

Several studies of obesity treatment in children have demonstrated the importance of parents’ participation in weight control programs. [129,130]

Parents can serve as role models, authority figures, and behavioralists to mold their children’s eating and activity habits.

Clinicians can influence children’s habits indirectly by teaching and motivating parents to use their authority effectively.

The greater independence of older adolescents means that clinicians should discuss health behaviors directly with them, although parents should still be encouraged to make the home environment as healthy as possible. [1]

COUNSELING STRATEGIESEvidence suggests that education alone is unlikely to elicit behavioral change. Consequently, it is necessary to move from a traditional advice-giving role to one which utilizes 'behavior change skills' in the counseling process. There are a wide range of skills and strategies that can be used to facilitate the discussion.

The 5A’s ApproachThe 5-A framework (Assess, Advise, Agree, Assist, and Arrange) has been used in behavioral counseling interventions such as smoking cessation and may be useful in helping clinicians guide interventions for weight loss. Initial interventions paired with maintenance interventions help ensure that weight loss will be sustained over time. [131]

As a child enters adolescence, practitioners must shift their guidance from the parents to the adolescent. The future health of adolescents requires that they begin to make responsible decisions about their own health.

The goals of a strength-based approach are to 1) raise adolescents’ awareness of their developing strengths and the role they can play in their own health and well-being and 2) motivate and assist them in taking on this responsibility. [132]

The strengths that an adolescent has are building blocks to better health. Youth with more strengths participate in more healthy behaviors. [132a]

In the medical office, using this approach means showing respect and kindness toward adolescents and conveying the belief that they have the ability to continue their positive health behaviors or to make a behavior change when needed. [132]

Every office visit is an opportunity to directly promote strengths in adolescents.

Explore strengths with questions such as: How do you stay healthy? What do you do for fun? What’s going well at school? What are you good at? What responsibilities do you have at home? If I were an employer, why would I want to hire you? [133]

Positive youth development is correlated with psychosocial thriving, physical health, and lower likelihood of engaging in negative or risky behaviors during the adolescent years. [134,135]

Readiness to changeIs used to assure that the message provided fits the mindset of the patient and family who are often the shoppers/cooks:

Stages of change theory describes cognitive stages that lead to behavior change. [136]

Precontemplation – An individual may initially be unaware of the problem – focus on why the change is important

Contemplation – Individual is becoming aware of the problem but still has no plans to address it – stress pros and cons, benefits

Preparation – Individual is planning for the new behavior – focus on getting started, steps and goals

Action – Finally the individual is beginning the new behavior – focus on strategies for success

Maintenance – Encourage continued behavior – anticipate obstacles and prepare for them

Relapse – Assist the person to identify what caused the relapse and set goals to resume the desired behavior

A clinician can help patients and families move through the stages, rather than prescribing a new behavior to those who are not ready.

Motivational interviewing with the Empathize/Elicit - Provide - Elicit model [1]A shared decision making approach that takes into account patients’ readiness to change, then encourages a dialogue with the adolescent to uncover motivations, strengths and barriers, allowing the adolescent to recognize and take steps towards healthier behaviors.

Motivational interviewing has been shown to be a promising approach to weight-control counseling in pediatric practice.

Principles:

Use nonjudgmental, nondirective questions and comments about the issues, e.g., a high BMI:

"Your BMI is above the 95th percentile. What concerns, if any, do you have about your weight?”

Next step depends on the response. This differs from a directive style, in which you inform the patient of the seriousness of the condition.

"Your BMI is quite high, so it is important to get your weight under control before it becomes a bigger problem. What is your understanding of the potential problems?”

Use reflective listening to uncover the beliefs and values of the adolescent:

So, it sounds like you have a pretty good understanding of some of the potential health problems. Would you like to talk about some ways that you could get down to a healthier weight? How ready are you to try to make a change or two (1-10 scale)? Are there things that you would like to do to lose some weight?

Use reflective listening again to uncover barriers to change:

Summarize his/her comments without judgment.

For example: "If I heard you correctly, you know you need to get more exercise, but you really don’t like to exercise, so you are not really ready.”

Reflections help build rapport and allow the patient to understand and to resolve ambivalence.

Elicit concerns of patients.

Compare values and current health practices:

If the adolescent values being healthy, then help him/her examine some different types of activities that he/she might enjoy, and be willing to try.

Use a shared decision approach - Evoke motivation, rather than trying to impose it.

What might need to be different for you to consider making a change in the future? And/Or

Could I give you some information about healthy activities [i.e. food choices] to help you think about this?

Help patient put together a plan that is consistent with this/her values.

The potential future health care costs associated with pediatric obesity and its co-morbidities are staggering -- the surgeon general has predicted that preventable morbidity and mortality associated with obesity may exceed those associated with smoking. [140,141]

Pediatric obesity is not an individual child's problem, but a problem that involves the entire family and the community. With no safe, effective pharmacologic agent on the horizon, there is no easy answer. Recommending a healthy diet and increased physical activity and counseling families on behavior change is the best approach to preventing and managing childhood obesity, but it is not easy. But it gets easier and more effective, the more it is practiced. [142]

If we remain complacent and expect overweight children to just "outgrow it," we will face even more alarming statistics in years to come. [143]

We checked your child’s BMI, which is a way of looking at weight and taking into consideration how tall someone is. Your child’s BMI is in the range where we start to be concerned about extra weight causing health problems.

Elicit parent’s/child’s concerns

What concerns, if any, do you have about your [child’s] weight? "He did jump 2 sizes this year. Do you think he might get diabetes someday?”

Reflect/probe

So you’ve noticed a big change in his size and you are concerned about diabetes down the road. What makes you concerned about diabetes in particular?

Assess sweetened beverage, fruit, and vegetable intake, television viewing and other sedentary behaviors, frequency of fast food or restaurant eating, consumption of breakfast, and other factors

(Use verbal questions or brief questionnaires to assess key behaviors)Example: About how many times a day does your child drink soda, sports drinks, or powdered drinks like Kool-Aid?

Provide positive feedback for behavior(s) in optimal range

You are doing well with sugared drinks.

Elicit response

"I know it’s not healthy. He used to drink a lot of soda, but now I try to give him water whenever possible. I think we are down to just a few sodas a week.”

Reflect/probe

So, you have been able to make a change without too much stress.

Provide neutral feedback for behavior(s) not in optimal range

Your child watches 4 hours of television on school days.

Elicit response

What do you think about that?"I know it’s a lot, but he gets bored otherwise and starts picking an argument with his little sister.”

Reflect/probe

So, watching TV keeps the household calm.

Step 2. Set agenda

Query which, if any, of the target behaviors the adolescent may be interested in changing or which might be easiest to change

We’ve talked about eating too often at fast food restaurants, and how television viewing is more hours than you’d like. Which of these, if either of them, do you think you and your child could change?

"Well, I think fast food is somewhere we could do better. I don’t know what he would do if he couldn’t watch television. Maybe we could cut back on fast food to once a week.”

Agree on possible target behavior

That sounds like a good plan.

Step 3. Assess motivation and confidence

Assess willingness/importance

On a scale of 0 to 10, with 10 being very important, how important is it for you to reduce the amount of fast food he eats?

Assess confidence

On a scale of 0 to 10, with 10 being very confident, assuming you decided to change the amount of fast food he eats, how confident are you that you could succeed?

Explore importance and confidence ratings with the following probes:

Benefits

You chose 6. Why did you not choose a lower number? "I know all that grease is bad for him.”

Barriers

You chose 6. Why did you not choose a higher number? "It’s quick and cheap and he loves it, especially the toys and fries.”

Reflection

So there are benefits for both you and him.

Solutions

What would it take you to move to an 8? "Well, I really want him to avoid diabetes. My mother died of diabetes, and it wasn’t pretty; maybe if he started showing signs of it; maybe if I could get into cooking a bit more.”

Step 4. Summarize and probe possible changes

Query possible next steps

So where does that leave you? OR

From what you mentioned it sounds like eating less fast food may be a good first step. OR

How are you feeling about making a change?

Probe plan of attack

What might be a good first step for you and your child? OR

What might you do in the next week or even day to help move things along? OR

What ideas do you have for making this happen?

If patient does not have any ideas

If it’s okay with you, I’d like to suggest a few things that have worked for some of my patients.

Summarize change plan; provide positive feedback

Involve the child in cooking or meal preparation, order healthier foods at fast food restaurants, and try some new recipes at home.

Step 5. Schedule follow-up visit

Agree to follow-up visit within x weeks/months

Let’s schedule a visit in the next few weeks/months to see how things went.

If no plan is made

Sounds like you aren’t quite ready to commit to making any changes now. How about we follow up with this at your child’s next visit? OR

Although you don’t sound ready to make any changes, between now and our next visit you might want to think about your child’s weight gain and lowering his diabetes risk.

a. Counseling is included in the preventive medicine visit codes. The total time spent with the patient and the amount of counseling time must be documented, and discussion items must be delineated in the medical record.b. These codes can be used for subsequent visits, including those with a nurse, counselor, or dietician.c. For nutritional therapy assessment and/or intervention performed by the physician, the evaluation and management codes should be used.

Do you have a program for adolescents?The program should have options specific for children and adolescents or should be targeted specifically for the child’s age group.

What type of counseling/behavior modification models do you follow?The program should provide behavior modification that (a) emphasizes positive efforts and rewards success, (b) is sensitive to child/adolescent body image issues, (c) is culturally appropriate, (d) incorporates family members both to change the environment and to reinforce progress, (e) incorporates all 3 elements of weight loss/management (behavior, eating, and activity), and (f) meets frequently enough to support the child’s efforts and to monitor progress toward established goals.

Do you offer nutrition and exercise counseling/education?Programs should provide nutrition and exercise counseling/education tailored to the needs of the adolescent or child. Programs should have trained professionals conducting the sessions.

Must participants purchase proprietary meals?What are the initial and long-term costs?Initial fees, proprietary meals, and recurring costs, and how they will affect the patient’s participation, should be factored into the costs of the program. Proprietary meals can be costly, and no studies have examined their effect for children or adolescents.

Do you offer culturally appropriate services?The program should offer culturally appropriate services.

What are your immediate and long-term weight loss results?Immediate weight loss should not be more than 2 lb/week. The percentage of clients who are able to maintain adequate weight loss should be determined.

What is your attrition rate?The likelihood of patient success in program can be gauged by inquiring about the program’s attrition rate.

Do you advocate complementary/alternative weight loss methods?Programs that advocate complementary/alternative weight loss methods should use researched or reasonably approved methods, without the use of over-the-counter medications or products.

ASSESSING BARIATRIC SURGERY SERVICES

Are you affiliated with a tertiary care center or pediatric hospital?Bariatric centers should be affiliated with a pediatric tertiary hospital.

Do you have specific guidelines for adolescents?There should be specific guidelines for adolescents.

What are your enrollment criteria?The enrollment criteria should include the following: (a) patients who have been unable to achieve significant reduction in BMI (<99th percentile) through nonsurgical means, including the use of medications, over a period of >6 months; (b) patients with BMI of ≥99th percentile or BMI of ≥40 kg/m2 who are demonstrating the complications of diabetes, cardiovascular disease, or other co-morbidities of obesity or patients with BMI of ≥50 kg/m2 without complications, and (c) patients and families that demonstrate the ability to follow the behavior modifications and adapt to the psychological burdens associated with the child’s condition and expected outcomes.

Do you have a multidisciplinary team (with mental health care workers, dietitians, exercise specialists, and case managers)?The center should have a multidisciplinary team (with mental health care workers, nutritionists/dietitians, exercise specialists, and case managers) with specific training to address pediatric concerns.

Do you offer preoperative and postoperative weight loss/behavior modification, with diet/exercise and/or medication?There should be both preoperative and postoperative weight loss/behavior modification, with diet/exercise and/or medication.

What surgical options do you provide?The surgical options should be approved for use in adolescents. Currently, Roux-en-Y gastric bypass is the only bariatric surgical procedure approved by the FDA for use in adolescents. However, other methods are currently in clinical trials.

What are the long-term potential complications? What are your long-term results?Long-term complications include delayed healing, multiple operations (including skin revision), and malnourishment. Immediate weight loss results should be within accepted guidelines, and long-term weight loss should be considered with respect to continued development.

What is the postoperative follow-up care, including duration?Postoperative follow-up care should include intensive nutritional guidance with attention to micronutrient balance and monitoring and psychological support for a minimum of 6 months to 1 year; this can be in an individual or group setting.

How are primary care/pediatric health concerns integrated?The primary care pediatrician should be integrated into the process so that ongoing pediatric health issues can be addressed and monitored after weight maintenance has been achieved.

What is the financial burden?The bariatric center should help in securing adequate financial support or facilitate minimization of the financial burden to the patient and family. It should be stated that the center will facilitate incorporation of the patient’s lifestyle changes (diet and special health needs) at the child’s school, to minimize the impact on the child’s psychosocial and educational environment.

U.S. Department of Health and Human Services. The Surgeon General’s Call to Action to Prevent and Decrease Overweight and Obesity. Rockville, MD: Public Health Service, Office of the Surgeon General, 2001.

U.S. Department of Health and Human Services. The Surgeon General's call to action to prevent and decrease overweight and obesity. Rockville, MD.: U.S. Department of Health and Human Services, Public Health Service, Office of the Surgeon General, 2001.

U.S. Department of Health and Human Services. Bone Health and Osteoporosis: A Report of the Surgeon General. Rockville, MD: Department of Health and Humans Services, Office of the Surgeon General, 2004.

Hayman LL, Meininger JC, Daniels SR, et al., for the American Heart Association. Primary prevention of cardiovascular disease in nursing practice: focus on children and youth. A scientific statement from the American Heart Association Committee on Atherosclerosis, Hyperten­sion, and Obesity in Youth of the Council on Cardiovascular Disease in the Young, Council on Cardiovascular Nursing, Council on Epidemiology and Prevention, and Council on Nutrition, Physical Activity, and Metab­olism. Circulation. 2007;116(3):344-357.

American Diabetes Association. Type 2 diabetes in children and adoles­cents. Diabetes Care. 2000;23(3):381-389.

US Dept Health and Human Services. The Surgeon General’s Call to Action to Prevent and Decrease Overweight and Obesity. Rockville, MD: US Department of Health and Human Services, Public Health Service, Office of the Surgeon General; 2001

Wolf AM, Colditz GA. Current estimates of the economic cost of obesity in the United States. Obes Res. 1998;6:97–106